“Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans – maybe even President Barack Obama – are being overtreated.

Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments?

A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits.”

I had picked up on that same theme in this week’s news:

• An independent panel convened this week by the National Institutes of Health confronted a troubling fact that pregnant women currently have limited access to clinicians and facilities able and willing to offer a trial of labor after previous cesarean delivery.

• A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.

• Controversy over “value-based insurance design” that tries to address the problem of underuse of proven treatments and overuse of certain surgeries and diagnostic tests that may be less valuable. (Kaiser Health News story.)

• Expensive prostate cancer treatments are winning out over the old standards, driving up the cost of treatment before there’s clear evidence that they improve outcomes. (MedPageToday.com story.)

“Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”

• And the letter to the editor that followed:

To the Editor:

I can only wish that Richard J. Ablin’s article had appeared years ago and spared me and probably many others needless pain and anxiety.

In 1997, at the urging of a couple of friends, I walked into a clinic feeling great and a bit foolish. P.S.A., 9-plus. Biopsy, of course (ouch), and I was told of a “little suspicious gray area” on a film. Lab test result, positive. Doctor recommendation: surgery or radiation.I decided against both and never looked back, and have lived happily and healthfully ever after.

By the way, the 10 or 15 percent chance of bad side effects (I asked) from surgery is really far higher, from what I’ve read and heard. Watchful waiting is still the best suggestion any doctor can offer.

Robert S. CoryaIndianapolis, March 10, 2010

• CBS’ Harry Smith’s live colonoscopy coverage that never touched on any questions about evidence for colonoscopy and some of the questions that have been raised about the overselling of colonoscopy – perhaps resulting in the decline in use of a $20 blood stool slide test.

While Smith’s colonoscopy was being televised, I was attending a meeting entitled, “First, Do No Harm,” hosted by the US Agency for Healthcare Research & Quality. The purpose of the meeting was to guide future AHRQ research on how to get doctors and patients to stop pursuing approaches for which there is net harm – not benefit. Clearly, health care in the US struggles even with the clearcut issues of cutting back in the face of net harm – much less in grey areas where there is uncertainty about harms vs. benefits.

But kudos to Lindsey Tanner of AP for trying to tie together the week’s news in the way she did. We could have stories like that every week. And if we did, we’d have a lot smarter health care consumer population.

Comments

Alan posted on March 12, 2010 at 10:10 am

There’s lot of inappropriate testing but it’s also true that there are many patients not being offered or using tests that actually have a net utility (e.g. tests in accordance with USPSTF guidelines).

Don posted on March 12, 2010 at 11:46 am

Thank you so much for your blog posting.
I agree and think that we as a nation have come to believe that a one pill treatment will ‘fix’ things….well, to some degree.
We are bombarded with advertising that states we can live a much better life with this particular medicine. Sometime advertising gives the symptoms and some people feel they might have this condition or that disease and ask, demand, request their physcian to do the test.
Do you think prescription companies should be banned from advertising, like they did with tobacco?

The management of scarce resources is a major issue that, I think, has the potential to transform our concept of medical professionalism and the relationship of doctors to patients in the coming decades. Physicians will be asked, increasingly, to change from an ethical framework that emphasizes doing to utmost for every patient, to one that emphasizes broader social outcomes.

This issue is not going away. We are organizing an event for the Seattle area on April 29th about medical guidelines. We will be bringing a wonderful ethicist, Wylie Burke, and others in medicine together to talk about Who Plays God: patient, doc or Uncle Sam?
Details are not final, but will be posted at the link for Northwest Science Writers, a nonprofit, when we have them. The public is welcome.

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